Nursing Elites

1. Who is responsible for obtaining the signature from the client on the informed consent?

• A. the staff nurse
• B. the charge nurse
• C. the LPN
• D. the physician

Correct answer: D

Rationale: The correct answer is the physician. It is the physician's responsibility to ensure that the client provides informed consent by obtaining their signature. While nurses play a crucial role in the healthcare team, their responsibility lies in verifying that the consent process has been completed correctly and advocating for the client. The staff nurse, charge nurse, and LPN do not have the authority to obtain the client's signature on the informed consent form, as this is within the scope of practice of the physician.

2. A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?

• A. turning off the room light and closing the door
• B. engaging the child in calming activities before bedtime
• C. identifying the child's home bedtime rituals and following them
• D. encouraging relaxation techniques like deep breathing exercises

Correct answer: C

Rationale: For a 4-year-old client struggling to sleep in the hospital, the best nursing intervention is to identify the child's home bedtime rituals and follow them. Preschool-age children often have specific bedtime routines that provide comfort and promote sleep. This familiarity can help create a sense of security in an unfamiliar hospital environment. Choice A, turning off the room light and closing the door, may increase the child's fear of the dark and being alone. Choice B, engaging the child in calming activities before bedtime, is a better choice than tiring them with play exercises. Choice D, encouraging relaxation techniques like deep breathing exercises, although helpful, may not be as effective as following the child's familiar bedtime routines.

3. A client states, 'I can leave the diaphragm in place as long as I want after intercourse.' Which statement indicates to the nurse that the client needs further information on how to use the diaphragm?

• A. 'I need to reapply spermicidal cream with repeated intercourse.'
• B. 'The diaphragm needs to be filled with spermicidal cream before insertion.'
• C. 'I can leave the diaphragm in place as long as I want after intercourse.'
• D. 'The diaphragm can be inserted as long as 6 hours before intercourse.'

Correct answer: C

Rationale: The correct answer is the statement, 'I can leave the diaphragm in place as long as I want after intercourse.' This statement indicates a lack of understanding about the correct use of the diaphragm. The diaphragm must be left in place for at least 6 hours after intercourse to ensure effectiveness and reduce the risk of pregnancy. Leaving the diaphragm in place for an extended period can lead to toxic shock syndrome. Choice A is correct as spermicidal cream needs to be reapplied before each act of intercourse for optimal contraceptive efficacy. Choice B is a correct statement as the diaphragm should be filled with spermicidal cream before insertion to increase its effectiveness. Choice D is also accurate as the diaphragm can be inserted up to 6 hours before intercourse to allow time for proper placement and effectiveness.

4. A nurse enters a client's room to administer a medication that has been prescribed by the health care provider. The client asks the nurse about the medication. Which response by the nurse is appropriate?

• A. 'I know that it's for fluid buildup, and I think you've taken it before.''
• B. 'It's called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in your diet.''
• C. 'It's to help get rid of the swelling in your feet.''
• D. ''You need to discuss this medication with your health care provider.''

Correct answer: B

Rationale: A client has the right to be informed of the medication name, purpose, action, and potential undesirable effects of a prescribed medication. The nurse should provide adequate information to the client. Choice B is the correct answer as it includes the medication name, its purpose (promoting urination and eliminating excess fluid), and a potential side effect (alteration in electrolyte levels) with a plan for managing it (increasing potassium in the diet). This response demonstrates thorough and complete information. Choice A provides some information but lacks details on potential side effects and dietary adjustments. Choice C is vague and does not provide specific details about the medication. Choice D deflects the client's question and does not fulfill the client's right to information.

5. An Asian family has an elderly member with the latest stage of Alzheimer's disease. The physician has recommended placement in a long-term care facility, but the family refuses. Which of the following is an appropriate response by the nurse?

• A. "You really need to listen to what the physician says."?
• B. "You will get too tired to take care of him at home."?
• C. "What can I do to assist you to care for him at home?"?
• D. "You are too busy to be taking care of an elderly person."?

Correct answer: C

Rationale: The correct answer is, "What can I do to assist you to care for him at home?"? This response shows cultural sensitivity and respect for the family's values. In many Asian cultures, there is a strong tradition of caring for elders at home rather than in a long-term care facility. By offering assistance to the family in caring for their elderly member at home, the nurse shows understanding and support. Choices A, B, and D are incorrect because they do not acknowledge or respect the family's cultural beliefs and values regarding caring for elderly family members.

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